Assessment of a Medication Deprescribing Tool on Polypharmacy and Cost Avoidance

According to the Centers for Disease Control and Prevention National Center for Health Statistics (NCHS), the use of prescription drugs has increased in the past half century. Although prescription drugs have played an important role in preventing, controlling, and delaying onset or progression of disease, their growth in use also has posed many risks.¹ One ramification of this growth is the occurrence of polypharmacy, which does not have a universal, clear definition. In general, it can be described as the concurrent use of multiple medications by a single patient to treat one or more medical ailments. Five or more medications taken simultaneously is the most common definition to date, but this is just one of many acceptable definitions and that varies from one health care facility to another.^1,2

Regardless of the cutoffs established to indicate polypharmacy, its incidence can result in poor and potentially harmful health outcomes. Polypharmacy increases the risk of experiencing adverse drug events (ADEs), drug-drug interactions (DDIs), geriatric-related syndromes, falls, hospitalization, and mortality. Issues with adherence may begin to unfold secondary to increased pill burden. Both the patient and the health care system may encounter financial strain, as polypharmacy can lead to unnecessary and essentially preventable costs of care. When evaluating the likelihood of polypharmacy based on age group, NCHS found that 47.5% of patients taking ≥ 5 medications were aged ≥ 65 years.^1-5 This indicates that polypharmacy is of great concern in the geriatric population, which also represents a large proportion of individuals accessing Veterans Health Administration (VHA) care.

Deprescibing

Deprescribing is the act of withdrawing or discontinuing potentially inappropriate medications (PIM), or medications used by older patients harboring ADEs that generally outweigh the clinical benefits of the drug. Deprescribing is an effective tool for managing or reducing polypharmacy. A variety of tools have been created whose sole purpose is to simplify deprescribing. Some tools explicitly identify PIM and are widely familiar in medical practice. Examples are the Beers Criteria developed in 1991 or Screening Tool to Alert Right Treatment/Screening Tool of Older Persons Prescriptions (START/STOPP) criteria created in 2003. Other tools that are less commonplace but equally as resourceful are MedStopper and Deprescribing.org. The former was launched in 2015 and is a Canadian online system that provides risk assessments for medications with guidance for tapering or stopping medications if continuation of the drug presents higher risk than benefit.^5-7 The latter is a full-fledged website developed by a physician, a pharmacist, and their research teams that serves as an exchange hub for deprescribing information.

In 2016, the VIONE (Vital, Important, Optional, Not indicated/treatment complete, and Every medication has an indication) deprescribing tool was developed by Saraswathy Battar, MD, at Central Arkansas Veterans Healthcare System (CAVHS) in Little Rock, as a system that could go beyond medication reconciliation (Table 1). Health care providers (HCPs) and pharmacists evaluate each medication that a patient has been prescribed and places each medication in a VIONE category. Prescribers may then take the opportunity to deprescribe or discontinue medications if deemed appropriate based on their clinical assessments and shared decision making.⁸ Traditionally, medication reconciliation involves the process of obtaining a complete and accurate list of medications as reported by a patient or caregiver to a HCP. VIONE encourages HCPs and pharmacists not only to ensure medication lists are accurate, but also that each medication reported is appropriate for continued use. In other words, VIONE is meant to help implement deprescribing at opportune times. More than 14,000 medications have been deprescribed using the VIONE method, resulting in more than $2,000,000 of annualized cost avoidance after just 1 year of implementation at CAVHS.⁹

VIONE consists of 2 major components in the Computerized Patient Record System (CPRS): a template and a dropdown discontinuation menu. The template captured patient allergies, pertinent laboratory data, the patient’s active problem list and applicable diagnoses, and active medication list. Patient aligned care team (PACT) pharmacists used the information captured in the template to conduct medication reconciliations and polypharmacy reviews. Each medication is categorized in VIONE using data collected during reviews. A menu delineates reasons for discontinuation: optional, dose decrease, no diagnosis, not indicated/treatment complete, discontinue alternate medication prescribed, and patient reported no longer taking. The discontinuation menu allowed PACT pharmacists and physicians to choose 1 VIONE option per medication to clarify the reason for discontinuation. VIONE-based discontinuations are recorded in CPRS and identified as deprescribed.

At the time of this project, > 30 US Department of Veterans Affairs (VA) facilities had adopted VIONE. Use of VIONE at VA Southern Nevada Healthcare System (VASNHS) in North Las Vegas has been incorporated in the everyday practices of home-based primary care pharmacists and physicians but has yet to be implemented in other areas of the facility. The purpose of this project was to determine the impact of the VIONE tool on polypharmacy and cost avoidance at VASNHS when used by primary care physicians (PCPs) and PACT primary care clinics.